A client has sustained a crush injury to the abdomen as the result of an industrial accident. The initial assessment and interventions have been carried out. The vital signs are stable and the family is at the bedside. The client is complaining of bilateral flank pain. What is the priority nursing action for this client now?
Prepare for immediate abdominal surgery
Determine if there are any allergies to food or drugs
Administer antibiotics as ordered after culture results are available
Obtain a urine specimen
The Correct Answer is D
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stop transfusion, run normal saline is correct because the client is likely experiencing an acute hemolytic transfusion reaction (AHTR), which is life-threatening. The priority is to stop the transfusion immediately and maintain IV access with normal saline to prevent further hemolysis.
B. Administer morphine IV is incorrect because pain management is important, but stopping the transfusion is the immediate priority.
C. Administer epinephrine IM is incorrect because epinephrine is used for anaphylaxis, not hemolytic reactions.
D. Continue to monitor the infusion is incorrect because the transfusion must be stopped immediately to prevent worsening hemolysis.
Correct Answer is B
Explanation
A. 20-gauge catheter in the right wrist infusing IV antibiotics
Infusing antibiotics can cause incompatibilities.
B. 20-gauge catheter in the right forearm infusing 0.9% Normal Saline
A 20-gauge or larger catheter in a patent IV site with compatible fluid (NS) is required for PRBC transfusion.
C. 22-gauge catheter in the left forearm infusing 0.45% Normal Saline
A 22-gauge catheter is too small for safe transfusion.
D. 18-gauge infusing 20 mg Potassium Chloride IV
Potassium chloride infusion should not be interrupted, making this site unsuitable.
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